INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 24, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ponessa Behavioral Health was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on June 24, 2025, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. The last date the fire extinguishers in the facility were inspected was January 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
SUD Director will review with property maintenance to ensure all fire extinguishers are inspected at minimum every year by 6/25/2025. All fire extinguishers will be inspected and approved by 7/2/2025. SUD Director will meet with property maintenance 1 month prior to all fire extinguisher inspection due dates to ensure an inspection is schedule and to ensure this citation does not happen in the future. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities for fiscal year 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
SUD Director will review with CEO the requirements to provide a copy of the obtained Financial Audit from a Certified Public Accountant at the time of the DDAP audit by 6/27/2025. SUD Director will ensure a copy of the financial audit for the previous fiscal year is provided by the due date of all pre-submission paperwork. SUD Director also applied for financial exemption on 6/25/2025. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information within 90 days of admission, per facility policy, in four of seven records reviewed.
Client #2 was admitted on August 29, 2024 and was active at the time of the inspection. A case consultation was due no later than November 29, 2024; however, one was not completed until December 10, 2024.
Client #3 was admitted on August 26, 2024 and was active at the time of the inspection. A case consultation was due no later than November 26, 2024; however, one was not completed until December 29, 2024.
Client #5 was admitted on August 15, 2024 and was discharged on May 05, 2025. A case consultation was due no later than November 15, 2024; however, one was not completed until December 2, 2024.
Client #7 was admitted on July 02, 2024 and was active at the time of the inspection. A case consultation was due no later than October 02, 2024; however, one was not completed until December 9, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
SUD Director will review with all staff the requirement to complete case consults every 90 days for the first year and then annually after that by 7/1/2025. It will also be reviewed that 2 signatures must be captured by the due date to be in compliance by 7/1/2025. SUD Director will review client list spreadsheets to ensure clinicians are up to date on case consults and complete monthly chart audits to ensure this does not happen in the future. |